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Maxwell, Virginia TOWN OF QUEEVBUJ� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director /X / xN Name /l //P2l1/A Case it Z Q Date of Cremat i cn ��7 /►� Time Cremation Started Time Cremation Completed 6 ' v 1, Type of Container Z)W,p � /zJ li/4 Ej d (AJ Remarks : A114 i N O 1� ✓� 3%1j NJ r� 4 TOWN OF QUEENSDURY PINE VIEW CEMETERY a CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-447*7 or if no answer Cemetery 745-4476 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains of: /`i (Name) (Sex) (�S v 006Y A/ Y. (Street ) (City) (State) (Zip Code) 2 ID who died on .�c3 day of OUi o c�(� 19 at (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation : (Name) (Address) Relationship to the deceased /C-7/v Name of Funeral Home_ IMPORTANT: I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body. (Circle One) I certify that I have the full power and •aut:horization to arrange for the cremation of the remains and to direct the disposition of the cremated remains, that any personal possessions have either been removed or may be destroyed, and agree to protect, defend and save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them by reason of or connected with the cremat.•io.n of said remains as directed, whether such claims or demands are or are not wholly group less, false or fraudulen t. A", (Witnes (Address ) f ilel') (Signature of Relative or Legal Rep. and Address) Signed on this date : REC'Afl & DENNY FUNFERAL S"-,ZVICE 53(quaker Rvaid QuetnAmry,New Yw-k- J (518)792-11 J4 "Customer's Designation of Intentions" Name of Deceased: "j, I - \11 A K V�(ELI Cremation: 16, L llu)i' Vit2k,/ (',1Jt5'1'11A7LL4— (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: W Burial at i4 A e,(z y - El Return to Family, 11 'Entombment at - 11 Other (specify): I hereby designate the Disposition of Cremated Remains and aamowledge receipt of a00py of this form. (Signav&re) (Printed Name) ozelationship to Deceased) (Address) b, AiV 1 -5 (r.l.ph...Numb-) -Cremated Remains which shall not have been claimed within 120 days from the date of cremation may be disposed of by this firm by placement in a columbarium. /j Rmted Name of Funeral Director Signature of Amp4rDirector Dat or Undertaker or Unde�� TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) Name of Person Making Disposition Signature Date #9 WHITE:F=wrJ Home Copy YELLOW:SO=*Co" PINIL.Crematory Copy CUSHMN Rev.496 ZBOOKLET AUTHORIZATION FOR CREMATION AND DISPOSITION ICE:THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. ATLON IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING gnd, ce warrant and represent that I/we have the full legal ht andathority to authorizethcremation,processing and p remains of Y/ (�(/�[/q A X (A((:; (hereinafter referred to as the"Deceased"). Name ot Deceased _ Date of Death :C 3 _1 Time of Death ����� ®AM. ❑PM. I/We hereby request and authorize 066A IV f Z)CWnl y (hereinafter referred to as the"Funeral Home")to Name Of Funeral H&ne take possession of and make arrangements for the cremation of the remains of the Deceased at PI AIG V I 1A1 (hereinafter referred to as the"Crematory")• el Name of Crematory I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custod of the Funeral Home. I/we understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of theDeceased are returned to the possession and custody,of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the Deceased as follows: Is special handling required? ❑Yes X No Describe Description of urn or container selected: Suitable for shipping: ❑Yes ❑No ❑ Deliver to Cemetery ShName and Address of Cemetery K Release to family �'v� A/-Dt5-,A4 Name of Designated Family Member to Receive Cremated Remains ElScattering at sea by Funeral Home or Funeral Home's agent ❑ Ship via U.S. Registered Mail To: Name: Address: ❑ Other Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United States Postal Service. The cremation, rocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all governing laws,le rules, regulations and policies of the Crematory and Funeral Home,and the following terms and conditions: 1. The remains of the Deceased will not he accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid cremation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible items attached to the cremation container prior to cremation. In the event the remains of the Deceased are received by the Crematory in a casket or other container constructed of metal, fiberglass, or other noncumbustible materials, I/we authorize the remains of the Deceased to be removed prior to cremation and placed in a combustible cremation container I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any lawful manner it deems appropriate. 2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard When placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type of implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased prior to cremation, and dispose of such items at its discretion. YWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO DO NOT = CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. lease initial one. Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased prior to cremation,and dispose of as indicated: Description of Implanted Device Disposition . .. i*o-° of_ If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home. 3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally and irreversibly destroyed by prolonged exposure to intense heat and direct flame. I/We authorize the Crematory to open the cremation chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough cremation. 4. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental fillings, jewelry, and other personal articles accompanying the remains of the Deceased, may he destroyed during the cremation process. I/We further authorize that if any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber~ they may he separated from the cremated remains of the Deceased and disposed of by the Crematory. 5. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but not limited to,hinges,latches, nails,jewelry and precious metals,and to dispose of such materials. 6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically pulverized to an unidentifiable consistency prior to placement in an urn or other container. 7. Unless an urn or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in a container which is not designed for any type of shipment. 8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated - _11 1 1 1 . t 1 1 . .1- t;_____._1 u____ -_,_,.L____LL it.._____... -----4,-- ;ATTQ0 cx AUTHORIZATION FOR CREMATION AND DISPOSITION BQO�LET HERE NOTICE:THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BNF©RE SIGNING I/We,the undereigned,ce ,warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and disposition of the remains of �(l iC��f/V!A �lA X 1t��.LL (hereinafter re�erred to as the"Deceased"). Name o D �y Date of Death Time of Death {,'tom' �,M. ❑P.M. I/We hereby request and authorize Z(;r ' ,�l ill (hereinafter referred to as the"Funeral Home")to Name o Fune H e take possession of and make arrangements for the cremation of the of the Deceased at (hereinafter referred to as the"Crematory"). Name of Crematory I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home. I/we understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the Deceased are returned to the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the Deceased as follows: Is special handling required? ❑Yes ❑ No Describe Description of urn or container selected: Suitable for shipping: ❑Yes ❑No ❑ Deliver to Cemetery Name and Address of Cemetery ® Release to family S 1A1 Q L.t"� 8.),b L--:-d Name of Designated Family Member to Receive Cremated Remains ❑ Scattering at sea by Funeral Home or Funeral Home's agent ❑ Ship via U.S. Registered Mail To: Name: Address: ❑ other Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United States Postal Service. The cremation, rocessing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all governing laws,de rules,regulations and policies of the Crematory and Funeral Home,and the following terms and conditions: 1. The remains of the Deceased will not he accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid cremation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible items attached to the cremation container prior to cremation. In the event the remains of the Deceased are received by the Crematory in a casket or other container constructed of metal, fiberglass, or other noncumbustible materials, I/we authorize the remains of the Deceased to he removed prior to cremation and placed in a combustible cremation container: I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any lawful manner it deems appropriate. 2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type of implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased prior to cremation, and dispose of such items at its discretion. WWE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO DO NOT = CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one. Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased prior to cremation,and dispose of as indicated: Description of Implanted Device Disposition Deetrfption of Implanted Device Disposition If no instruction for disposition is given,such items may be disposed of at the discretion of the Funeral Home. 3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally and irreversibly destroyed by prolonged exposure to intense heat and direct flame. I/We authorize the Crematory to open the cremation chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough cremation. 4. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental fillings, jewelry, and other personal articles accompanying the remains of the Deceased, may be destroyed during the cremation process. I/We further authorize that if any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber, they may be separated from the cremated remains of the Deceased and disposed of by the Crematory. 5. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but not limited to,hinges,latches,nails,jewelry and precious metals,and to dispose of such materials. 6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically pulverized to an unidentifiable consistency prior to placement in an urn or other container. 7. Unless an urn or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in a container which is not designed for any type of shipment. 8. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated